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Steve MacArthur

Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

Infant abduction drills

There’s nothing I like more than questions from the studio audience, so this week I thought I’d field a question on one of those risks that never seems to go away completely, as much because there are not very many specific requirements. So, let’s consider abduction drills.

The current situation at this particular organization involves what I think is a pretty good cross-section of activities: campus-wide drills, suspicious person(s) on the unit drills, mother/baby-specific drills, as well as random quizzing of staff throughout the organization on their role(s) in the infant abduction policy (they have to answer 10 questions about the policy), and a monthly operational test of the infant security alarm system. Again, I think that’s a very good start to things. But it does sort of beg the question as to what requirements exist? Well, dear reader, I beg you, please read on.

Strictly speaking, The Joint Commission (TJC) does not have a great deal that could be characterized as requirements in this regard. EC.02.01.01 EP #9 requires hospitals to have written procedures that can be acted upon in the event the hospital experiences any security incident, including abductions of infants of pediatric patients. That’s pretty much all there is in the standards. I’m presuming that you have a written procedure for responding to an infant and/or pediatric abduction incident, so we’re off to a good start. [more]

Mirror, mirror on the wall … is that me?

One of the curious things I encounter on an increasingly regular basis is the Dorian Gray-like (but in reverse) effect of the ID badges of folks who’ve worked at an organization for a rather long time. So long, in fact, that they really don’t look like their ID pictures any more. I know you’ve seen it too.

Now, I’ve always considered the hassle of having folks wear ID badges as being an important component of our security management strategies. As a general consideration, we do have an obligation to ensure that we’re not giving any interlopers a chance of breaching our security (and don’t get me started on those folks who are not nearly as careful about their ID badges as they should be. I know it makes me sound petulant, but we really ask so little of folks in this regard).

So, I ask those of you responsible for the ID process, have you established criteria for an update of photo IDs? Weight loss or gain, hair color changes, the aging process (all potentially contentious topics for discussion)? Or, like the motor vehicle registry folks, do you re-take pictures after a certain amount of time, maybe contingent on how much a person has changed in the ensuing period. Any feedback or discussion would be most appreciated.

Keep the home (and OR) fires not burning

I was not able to attend the recent NFPA conference in Las Vegas, but I have heard tell that there was some indication that beginning this year (2012) organizations can anticipate some closer attention being paid to all things in the surgical fire realm. I don’t know that this is one that has ever really gone away (fairly surveyor-dependent from my experience), but it appears that this will increase as a topic of survey conversation. (I suspect that the EC-LS survey process is going to continue to focus on the surgical environment-lots and lots of risks to be managed and not necessarily the easiest audience to capture when it comes to safety and related education).

Among the items that will likely surface in conversation:

  • Fire drills and education for surgical staff
  • Fire response procedures
  • Risk assessments to minimize the risks of surgical fires and/or injuries
  • The roles and responsibilities of physicians in the management of the above-noted considerations

As a final thought in this regard, don’t forget that the grand ol’ folks at CMS take this pretty seriously and there have been instances in which an inadequate response from frontline surgical staff (the metaphorical equivalent of the “shrug,” maybe even metaphysical as well, but we’ll leave that for another time) drove an Immediate Jeopardy finding. When it comes to areas of greatest risks for conflagration, the surgical environment is right there at the top of the pyramid. So, we need to make sure that everyone in that environment understands the whole picture: preparedness, mitigation, response. This is way too important to leave to chance, so let’s get to it!

It’s so easy, it’s so easy, it’s so easy (repeat ad infinitum)–so doggone easy!

When you compare it to sustaining improvement, actually making the improvements to start with is rather like the proverbial piece of cake.

One of the common themes I’ve been running across (and sometimes running into) in my consulting work is the frustration that comes with encountering conditions and/or practices that the organization thought had been resolved. And it’s generally not big ticket stuff and it’s generally not the types of things for which additional education is going to be making a significant difference. [more]

Permission comes in all shapes and sizes

Quick question—do you folks have conditions or practices in your facilities that might be a little squishy relative to a strict interpretation of regulatory codes, but your local AHJ has seen fit to grant you permission to engage in that pursuit? And, if so, have you also used that permission to request a traditional equivalency from TJC?

You haven’t?!? Well, my advice would be to do so with all due haste (you can request an equivalency either using snail mail or as an online submittal through the electronic Statement of Conditions on the Joint Commission Connect site). [more]

How is your generator like a Great Dane (and no, I’m not referring to Hamlet…Marmaduke, maybe)?

I was recently looking over some survey results in which a finding was generated (small pun intended) because there was a “black substance coming out of the exhaust manifold” which was equated with evidence of wet-stacking. The finding went on to indicate that the condition needed to be addressed to prevent the potential for engine failure, while also indicating that all maintenance and testing had been performed as required.

Now, I will freely admit that I am in no way an expert when it comes to engines and the like, be they emergency generators or whatever. But, I am reasonably certain that if maintenance and testing activities are being performed as required, this “black substance” may very well have an explanation that does not necessarily point to some sort of catastrophic failure event.

And so, I have become introduced to the concept of exhaust manifold and/or engine “slobber.” [more]

Don’t pass/fail me by – what does it all mean…

I was recently reviewing some fire alarm testing documentation and I encountered an interesting dichotomy in which a number of smoke detectors were identified as having passed the inspection/testing process, but were also identified as having been installed within 3 feet of air supply vents. [more]

Watching the detectors

This week’s topic of conversation is the fascinating story of having smoke detectors in staff sleep rooms, and how TJC is surveying things at the moment.

So, a bit of background. Generally speaking, chapter 19, the existing healthcare occupancy chapter of the Life Safety Code (NFPA 101 – 2000) does not specifically require the installation of smoke detectors in physician sleeping rooms that are within the healthcare occupancy. It is also the case that physician sleeping rooms in other occupancies, particularly Hotels and Dormitories, would certainly indicate the need for smoke detection. [more]

How will you know?

One question that comes up from time to time in survey encounters with front-line clinical staff is the very open-ended: How do you know that this piece of medical equipment is safe/ready/OK to be used?

Then there’s generally some conversation regarding the proper operation of the device—making sure there are no error messages, the device powers up, etc. Sometimes, the conversation will also cover the topic of what I will generically call the inspection sticker.

Last Dance, Last Chance—Hot (& humid) Stuff…

Strangely enough, there remains some uncertainty relative to the management of temperature and humidity, particularly in the surgical environment. And the topic of this week’s conversation is: What do you do when your HVAC system is not functioning within its designed specifications? [more]